Residents at the Newtown Rehabilitation & Health Care Center were left in their beds for hours without trips to the bathroom or diaper changes and received food late and cold, while nursing aides reported having as many as 20 residents to care for during some shifts, according to an inspection report released by the state.
The Newtown facility, an embattled nursing home owned by Athena Health Care Systems, was issued a finding of “immediate jeopardy” earlier this month, meaning violations in the home caused or were likely to cause serious injury or death to a resident.
Inspectors with the state Department of Public Health concluded that the facility failed to provide adequate staffing levels to ensure residents received timely care, resulting in neglect to 20 residents they observed.
“Based on the deficiencies during the survey, immediate jeopardy and substandard care was identified in the areas of freedom from abuse and neglect and sufficient nursing staff,” they noted.
The inspectors also faulted the nursing home for failing to ensure staff followed infection control practices and for failing to maintain documentation on resident care, quarterly infection control meetings and medical director rounds.
Athena was issued the finding of immediate jeopardy on Jan. 13 and moved quickly to correct the problems. The administrator of the facility was notified of the finding at 6:50 p.m. on Jan. 13, and the facility submitted a “removal plan” just over four hours later, at 11:04 p.m., the report states.
The immediate jeopardy finding was lifted on Jan. 15, state health officials said.
The health department has asked Athena to continue halting admissions at Newtown until further notice, however. The company agreed to do so.
In a statement, Lawrence Santilli, president and CEO of Athena, said staffing has “significantly improved” in recent weeks.
“We have worked tirelessly since Immediate Jeopardy was issued to improve our staffing,” he said. “At this present time, we are staffing over what is required on all shifts. Internally, we looked at our wage structures between shifts, and I personally spoke with our [certified nursing aides] on my multiple visits to the center and immediately put in place an effective plan to ensure our staffing is over which is required.
“We have in place quality programs, including increasing the frequency of rounds on units, weekly rounding with our medical director, growth of our Ambassador Program, comprehensive review of staffing reports, ongoing efforts with our resident satisfaction surveys and reinforcing our grievance procedures to residents and families.”
The 71-page inspection report released by the health department details the conditions that triggered the immediate jeopardy order. Inspectors visiting the facility noticed a resident in a “hospital-type Johnny coat” with no pants on sitting in a dining area “with a puddle of urine underneath the wheelchair.”
They also encountered many residents who had not been removed from their beds by midday despite having orders to be moved every two hours because of concerns about skin ulcers. Several were found in urine-soaked and feces-stained diapers with skin ulcers developing in several areas, according to the inspection report.
DPH investigators interviewed one resident who said they “frequently had to wait a long time for [the] call bell to be answered, food was delivered cold, and often missed scheduled showers.”
“Imagine you are sitting in a wet and cold diaper for hours,” the resident said. “You get a urinary tract infection because there was no staff to change you and when the [nursing aide] comes into your room, she tells you, ‘I am here by myself and have 20 residents, so you have to wait.’”
In interviews with staff, several nurse’s aides reported large resident case loads. One described having 18 patients assigned to them; another, 18 to 20, and a third, 17 to 20.
One aide on the morning shift told inspectors she was to care for 18 residents that day, and nearly four hours into the shift, she still had not seen six of them. Eleven who needed care for incontinence every two hours did not receive it, she said.
The aide “indicated it was impossible to provide care for the 18 residents on her assignment timely; she indicated the facility could not expect one [nurse aide] to provide incontinent care to 18 residents every two hours,” the inspectors wrote in their report.
An interim director of nursing told health officials the facility needed 13 to 14 nurse aides to staff the 7 a.m. to 3 p.m. shift “to provide care in accordance with resident needs,” and on the day of the inspection, eight aides were working.
“Review of the resident roster identified the second floor had 71 residents with four NAs (ratio 1 NA to 18 residents),” the inspectors wrote. “The interim [nurse director] stated that she was aware that the NA staffing levels were not what was needed to provide care to the residents, and she was working with a nursing agency to obtain additional staff and was working to hire more facility staff.
“Although the interim [nurse director] indicated she was aware the shift had less than the required NAs to provide resident care, [she] was unable to explain what measures she implemented/steps she took to ensure residents received care timely during the shift.”
An administrator interviewed by inspectors said he was “unable to verbalize how [a nurse aide] was provided with direction/assistance with her assignment or what steps were taken to ensure the facility had adequate staffing on each shift.”
“The administrator further identified that the facility does not have a staffing policy,” the inspectors wrote in their report.
State health investigators said they reviewed the electronic medical records of more than 20 residents who required assistance getting out of bed and with incontinence problems. From Jan. 1 to Jan. 17, the records show that several residents did not have their diapers changed during more than half of the 51 shifts during that time frame.
In some of the worst cases, the records showed residents did not receive care for as many as 34 of the 51 shifts reviewed.
An interim nursing director said that although daily care was “most likely provided,” the lack of documentation suggested “the care was not provided,” inspectors wrote.
During a Jan. 14 visit, inspectors observed nursing aides leaving resident rooms wearing gloves, carrying soiled linens or briefs in their hands and touching linen cart lids and door knobs.
One of the aides “failed to wash or sanitize her hands after removal of the soiled gloves and was observed to assist a resident to their room by holding the resident’s hand while ambulating,” the inspectors noted.
At the time of the review, 129 residents lived at the Newtown facility, records show. A spokesman for the company said the census was 114 as of Jan. 30.
In letters to Athena on Jan. 18 and Jan. 30, officials with the health department said they are recommending to the Centers for Medicare and Medicaid Services that a civil money penalty be imposed. They did not specify the amount.
The health department also ordered Athena to hire an independent nurse consultant to ensure the safety and well-being of residents and to oversee corrective action at Newtown Rehabilitation. The nurse consultant will be at the home 24 hours a week.
During the last quarter, the health department issued four immediate jeopardy findings in Connecticut. In general, there has been an increase in those orders, at least partially due to staffing issues in nursing homes, Barbara Cass, chief of DPH’s health care quality and safety branch, said at a public meeting recently.
Athena operates 21 nursing homes in Connecticut from Middletown to Sharon and serves more than 2,500 residents. Another Athena facility, Middlesex Health Care, is operating under a consent order signed last summer.
The consent order required Athena to hire an independent nurse consultant who reports weekly to the health department on patient care, staffing levels and food delivery. Athena also agreed not to take any new admissions at that facility.
Mairead Painter, the state’s long-term care ombudsman, said the Newtown facility was among the five Athena homes that received the most complaints between October 2021 and September 2022. The others were Middlesex Health Care Center in Middletown, Valerie Manor in Torrington, Abbott Terrace Health Center in Waterbury and Bayview Health Care in Waterford.
Athena has recently been under pressure from lawsuits by temporary employment agencies to questions about patient care in facilities in three New England states.
Athena was recently fined $1.75 million by the Massachusetts Attorney General’s office for admitting substance abuse patients to its facilities in that state without having the proper staffing to care for them. In the settlement with Athena, state officials said there were at least 12 overdoses.
The company also has been the subject of consent orders in Connecticut, Massachusetts and Rhode Island.